Provider Demographics
NPI:1821166067
Name:EDISON MEDICAL PHARMACY INC
Entity Type:Organization
Organization Name:EDISON MEDICAL PHARMACY INC
Other - Org Name:EDISON MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPHOWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVINCHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-533-2535
Mailing Address - Street 1:4240 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2288
Mailing Address - Country:US
Mailing Address - Phone:773-533-2535
Mailing Address - Fax:773-533-2535
Practice Address - Street 1:4240 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2288
Practice Address - Country:US
Practice Address - Phone:773-533-2535
Practice Address - Fax:773-533-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540093373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020547OtherPK
IL=========001Medicaid
IL4564240001Medicare NSC